SCIENTIFIC CONFERENCE

Placental thrombosis venous lake and IUGR: A case review

Narasumber
Dr. dr. Yuditiya Purwosunu, SpOG, PhD
CASE ILUSTRATION
 CASE Mrs. D, 35 yo
23/01/2023 23/01/2023
ER 3rd Floor ER 3rd Floor

Patient came with complain of decreased fetal movement, Physical examination

patient was admitted 30 weeks gestational age, LMP was Forgotten, EDD 30/03/23 ~ 30+1
General status: CM, BP 117/71 mmHg , HR 91x/mins, T 36.7 C, RR 20
week, patient claimed ANC routinely at Ummi Bogor Hospital with obstetrician, at 22 weeks
gestation, it is said that the fetus tended to be IUGR, patient was referred to Fetomaternal x/mins; Eye CA (-), SI (-)/ Heart S 1-2 regular, murmur (-)/ Pulmo
RSCM. The patient was then routinely ANC with doctor Yudianto, treated with heparin, vesicular +/+, wheezing -/-, rales -/- abdomen enlarged ~ pregnancy/
laneson and voxib, at the obstetrics clinic the patient was diagnosed as IUGR and absent edematous extremities -/-
end diastolic, then patient control at the high-risk clinic for 1 time and planned for SC at 30
weeks of gestation 1/26/23, and it was planned to complete laoratorium screening and Obstetrics status
perioperative consult, but 1 day before admission, the patient complained of reduced fetal
TFU at navel, Contraction - , head presentation, FHR 159 bpm
movement, so the patient decided to go to RSCM, no contractions, no water broke, no
spotting, no vaginal discharge, There is no water broke, defecation and mixturirion in within I: V/U wnl, no active bleeding
normal limit Io: portio smooth, livid, OUE closed, fluxus (-), fluor (-)
VT: not done
Previous history
HT (-), DM (-), asthma (-), heart disease (-) allergy (-), Smoking (-) USG IGD:
Family: (-)
ER US exam (22/1/23) :
Menstrual, obstetric, marital, family planning history Singleton live head presentation, Placenta on fundal extend to
Menstruation: menarche 13 yo, irregular, 5 days, 28 days/cycle, dismenore (-) posterior
Marital: 1x, since 2013 BPD/HC/AC/FL 62/239/188/41
Obstetric: G6P1A4 EFW 633 gram, ICA 2,03
1. 2013 abortion and curettage by doctor on 6 weeks gestational age - RS. melania, Bogor Umbilicalis artery absend end diastolic
2. 2014, abortion 6 weeks gestational age, not curettage RS. Yuliana, Bogor
3. 2015, abortion, 9 weeks gestational age, missed abortion, not curettage clinic at bandung
4. 2016 girl, 2200g SC due to hypertension, 38 weeks gestational age Lab(20/1/23)
5. 2022 complete abortion 5 weeks gestaional age CBC 11.4/34.5/9580/226000//94.5/31.2/33.0
6. This pregnancy Ferritin 115.81; CRP/PCT 1.1/0.04
Family planning: IUD 2 years RPR/TPHA Non reaktif/Non reaktif; Na/K/Cl 135/3.7/105.3
Social: Patient: Lecture (S2) , husband : entrepreneur GDS 82, Ur/Cr/eGFR 21.4/0.50/125.8; SGOT/SGPT 16/17, PT/APTT
History of operation : SC in 2016
0.8x/0.8x 
 CASE Mrs. D, 35 yo
23/01/2023 23.00-01.00
23/01/2023
ER 3rd Floor
ER 3rd Floor
 OT ER 4th floor

Contraction, bloody show (+), active fetal movement. On going Caesarean section at ER 4th floor
Plan:
O: composmentis - Observation Vital sign, ueterine contraction, and bleeding
BP : 119/84 mmhg, HR : 89 bpm, RR 18x/min, T : 36,5C - IVFD RL + Oxytocin 20 IU/ 8 hours
General physical examination within normal limit - Ketorolac 3x30mg IV
Obstetric examination: - SF 2x300mg PO
Irreguler Contraction, FHR (+) 148 bpm. - CaCO3 3x500mg PO
Inspection: vulva/urethra within normal limit, no active bleeding - Mobilization
CTG : categori I - CBC Evaluation post caesarean section
Laboratory: - Removal of urine cathetetr after 24 hours
DPL 13.5/35.4/15460/239000//82/31/38 - High protein diet

A : G6P1A4 30+1 weeks of gestation age, singleton live head presentation,

IUGR, absent end diastolic, oligohydramnios (AFI 2), mother with recurrent
pregnancy loss, previous C-section 1 time

P:
Discussion with DPJP Dr. dr Yuditiya Purwosunu, SpOG(K), PhD
Patient with recurrent pregnancy loss with multifactorial causes and in this
pregnancy having an IUGR fetus and abnormality in doppler examination with
absent end diatolic decide to perform abdominal termination by caesarean
section at the ER 4th floor.

SC + IUD emergency
 ANC table
06/08/22 27/08/22
Ummi Hospital Ummi Hospital
S : First ANC S : Second ANC

O: O:
US exam: US exam:
Uterine retroflexed
Uterine retroflexed, singleton live intrauterine
GS (+) 2.45cm
CRL 2.50cm, ~9-10 weeks of gestational age
CRL 0.47cm
YS 0.53 cm CRL 0.47cm
EDD 24/03/2023 FHR (+) 158 bpm

A: G6P1A5 6-7 weeks of gestational age, singleton live intrauterine, mother A: G6P1A5 9-10 weeks of gestational age, singleton live
with suspected APS intrauterine, mother with suspected APS

P: P:
- ANC routine after 3 weeks - ANC routine after 4 weeks

01/10/22 19/11/22
Ummi Hospital Ummi Hospital
S : Third ANC S : fourth ANC
BW: 53.2 kg; BP 100/70 mmHg
O: O:
US exam: US exam:
singleton live intrauterine
Singleton live intrauterine
EFW 93 gram, FHR (+), AFI wnl
EFW 282 gram, FHR (+), AFI 10.56 cm
CRL 7.6 cm
Placenta at posterior corpus to OUI Placenta not covering OUI, placentomegali with suspected
placental haematome
A: G6P1A5 14-15 weeks of gestational age, singleton live intrauterine,
mother with suspected APS A: G6P1A5 22 weeks of gestational age, singleton live intrauterine,
small for gestational age, with placentomegali, mother with
P: suspected APS
- ANC routine after 4 weeks
P:
-
 ANC table

24/11/22
Gulardi
fetomaternal Clinic
S : Third ANC with fetomaternal consultant

O:
US exam:
singleton live intrauterine, FHR (+), fetal activity and tone within normal
limit
Fetal biometry ~22 weeks, EFW 308 gram (percentile 7).
Fetal morphology hard to evaluate in contraction and fetal already egaged.
Placenta at posterior corpus, thickened placental with subamnion
haematome dd/ thrombosis vonous lake, implantasi normal. Grade 2,
placental border further from OUI, AFI 12.8 cm. placental chord with 2
areteries and 1 vein
Shortening of the cervix 6mm and funelling. Notching at 2 uterne arteries

USG ~22 weeks of gestational age, fetal activity normal, IUGR at percentile 7
with absent end diastolic, Fetal morphology hard to evaluate in contraction
and fetal already egaged. Placenta at posterior corpus, thickened placental
with subamnion haematome dd/ thrombosis vonous lake

A: G6P1A5 22 weeks of gestational age, singleton live intrauterine, IUGR,

absent end diastolic, mother with suspected APS

P:
- Routine ANC every 2 weeks
 ANC table

08/12/22 24/12/22
Gulardi Gulardi
fetomaternal Clinic fetomaternal Clinic
S : First ANC with fetomaternal consultant S : Second ANC with fetomaternal consultant
BW: 56 kg; BP 140/90 mmHg
O: Blood test: Hb 9.9/Leucocyte 9000/Monocyte 9.2/LED 70; Ferritin
173.17; Urinaysis wnl O:
US exam:
US exam:
singleton live intrauterine, FHR (+)
singleton live intrauterine, FHR (+)
EFW 401 gram
EFW 553 gram
A: G6P1A5 22 weeks of gestational age, singleton live intrauterine, IUGR, AFI normal
mother with suspected APS CPR > 1

P: A: G6P1A5 26 weeks of gestational age, singleton live intrauterine,

- Heparin 1x5000 IU IUGR, mother with suspected APS
- Cal 95 3x1 PO
- Vit D3 1x5000IU PO P:
- Lameson 3x1 PO - Heparin 1x5000 IU
- Voxib 2x1 PO - Cal 95 3x1 PO
- Herclov 2x500mg PO
- Vit D3 1x5000IU PO
- Rouitne ANC after 2 weeks
- Lameson 3x1 PO
- Voxib 2x1 PO
- Routine ANC every 2 weeks
 ANC table

02/01/23 09/01/23
Gulardi Gulardi
fetomaternal Clinic fetomaternal Clinic
S : Third ANC with fetomaternal consultant S : Second ANC with fetomaternal consultant
BW: 56 kg; BP 140/90 mmHg
O:
US exam: O:
singleton live intrauterine, FHR (+)
US exam:
EFW 666 gram
singleton live head presentation, FHR (+)
AFI 7.18 cm
Placenta not covering OUI EFW 720 gram
AFI normal
A: G6P1A5 28 weeks of gestational age, singleton live intrauterine, IUGR, Absent end diastolic
mother with suspected APS
A: G6P1A5 29 weeks of gestational age, singleton live intrauterine,
P: IUGR, mother with suspected APS
- Rouitne ANC every 2 weeks
P:
- Heparin 2x5000 IU
- Cal 95 3x1 PO
- Vit D3 1x5000IU PO
- Lameson 3x1 PO
- Voxib 2x1 PO
- Routine ANC every 2 weeks
 ANC table
17/01/23
Obstetric clinic
RSCM

Patient referred from Bogor General Hospital, with IUGR

Fetomaternal US examination
and suspected RPL, plan for confirmation of ultrasound
Singleton live head presentation
exam by fetomaternal consultant and advance medical
BPD/HC/AC/FL 62/233/185/43
treatment at RSCM.
EFW 630 gram
AFI 5.2 cm
Obstetrical history
Obstetric: G6P1A4
A : G6P1A4 29 weeks of gestational age, singleton live head presentation,
1. 2013 abortion and curettage by doctor on 6 weeks
IUGR, absent end diastolic, mother with suspected APS
gestational age - RS. melania, Bogor
2. 2014, abortion 6 weeks gestational age, not curettage
P:
RS. Yuliana, Bogor - Referred to high risk clinic
3. 2015, abortion, 9 weeks gestational age, missed - Work up for RPL laboratories
abortion, not curettage clinic at bandung
4. 2016 girl, 2200g SC due to hypertension, 38 weeks
gestational age
5. 2022 complete abortion 5 weeks gestaional age
6. This pregnancy

O: composmentis
BP : 145/93 mmhg, HR : 86 bpm, RR 18x/min, T : 36,5C
General physical examination within normal limit
Obstetric examination:
Contraction negative, FHR (+) 131 bpm, FH 27 cm
Inspection: vulva/urethra within normal limit, no active
bleeding
LITERATURE
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